New Client Intake Form

Full Legal Name

Date of Birth

Current Physical Address

Email Address

Phone

Number of People in Your Household (Including yourself)

Please list the name, age, and relationship of other members of the household. Enter N/A if not applicable.

Are you currently employed?

Are you a domestic violence survivor?

Total Monthly Income

Income Source

What type of assistance your seeking?

What is your relationship to the person who is harming you?

Spouse

Ex-Boyfriend/Ex-Girlfriend

Live-In Partner

Other

What brought you to our program? Share only what you're comfortable with sharing, as your answer to this question is voluntary. We keep this information confidential and won't share with anyone without your permission, unless you are in immediate danger.

Some people experiencing abuse use alcohol or drugs to help them cope. We are here to support you and can connect you to resources that match your needs. Is this something you would like help with?

We work within our community to connect our survivors to services that support them. Please check any services you are interested in learning more about.

Do you have someone who you can trust with your safety planning? If so, list their name, relationship and contact number below. Otherwise, respond with N/A.

Please upload a copy of your photo ID or any document (piece of mail, bill, etc.) that identifies you.

***By signing this application, the applicant certifies that all of the above information and attachments are true and correct to the best of the applicant's knowledge and belief. Applicant agrees that the actual provision of assistance, if approved will be in accordance with the policy of Our 3 Memorial Foundation, Inc.

Signature